Welcome! Blood, guts, trauma, surgery, and life saving intervention keep us on the adrenaline roller coaster of the ER. Of course, it's not always positive. The ER can be an emotionally taxing and sometimes heartbreaking workplace, and this blog serves as an outlet for the stress of making life and death decisions each and every day.

Tuesday, January 24, 2012

Unfortunately, in my line of work, I see a lot of grieving people from all different causes; unexpected tragic losses to expected but not quite ready long term cancer patients. I am extremely sympathetic, as I love my own pets dearly and know what it feels like to be on the other side of the exam table.

I am no psychologist, but from experience, I can tell you that there are many variations of normal grief. Some people hide their tears and break down once they walk out of the room, others cry openly and accept my condolences and even a hug after their pet has passed. Others do not talk, and some are even slightly rude with the reception staff at the counter. 99% of my clients grieving, even given the most extreme circumstances, thank me for helping their pet at their final minutes, and are courteous and kind.

Yesterday, I had the misfortune of dealing with someone who could not control herself, and took it out on me and my staff.

"Sissy" was her cat, a 14 year old domestic longhaired cat with extreme difficulty breathing. At triage, my technicians immediately recognized the urgency and placed Sissy on oxygen. The client had stated that an asthma attack was the cat's presenting complaint, that she had had this before, and she had been trying to wait for her veterinarian to open (in another 24 hours). Sissy was cyanotic (blue gums), and very pale. She was open mouth breathing and fluid was coming from her nose, and she had a low body temperature. When I listened to her chest, I heart a high heart rate and moist lung sounds, or "crackles" that often occur when fluid builds up. The most likely causes of these findings is congestive heart failure, however other possible diagnoses (or 'differential diagnoses' in medical terminology) include pneumonia, neoplasia, or asthma. These differentials were much less likely given the picture as a whole, but none of the possibilities can be completely ruled out without testing, like chest radiographs (x-rays) or an echocardiogram (ultrasound of the heart).

I went into the exam room. I inquired further about the history; it turns out that Sissy had never had any testing to confirm asthma, furthermore she had not had any treatment or flare-ups in 4 years. This is not consistent with asthma, and certainly my physical exam findings were not consistent with asthma as the most likely diagnosis. I recommended oxygen, chest radiographs, and hospitalization with medications to be determined based on imaging. The client refused any testing and screamed at me. "JUST GIVE HER A STEROID SHOT! ALL SHE NEEDS IS A STEROID SHOT!!"

Steroids are a prime treatment for asthma, however can worsen heart failure. I explained this to the client, as well as the findings that did not go along with asthma. I discussed that we could try medications alone, but that Sissy might decline. I also discussed that given her critical condition, even with all diagnostics and no limitations, she was at risk for sudden death or respiratory failure. I have pulled cats back from this condition before, but there are no guarantees in medicine. Further complicating the issue was that the client did not want to spend any of her own money on her cat.

The client screamed at me again. She then put her hand up in my face, dialed her phone, and called someone. I excused myself to go check on her cat, as well as to give her time to make her call, despite her rude behavior.

Five minutes later, I came back into the room. Her sister had joined her and was also hysterical. "CAN'T YOU JUST FIX HER? FIX HER! WHY CAN'T YOU JUST FIX HER?!" Calmly, I explained the medical situation again, and that I could definitely try to fix their cat, but ultimately, the clients decided upon euthanasia.

Sissy had been resting in our oxygen-enriched incubator, where she was still struggling to breathe, but had more comfort than the room air environment. I explained this to the client. I offered for her to come sit with Sissy while we provided oxygen via a face mask to help her stay comfortable.

I brought the client to the treatment area, and an assistant placed Sissy in her arms with a blanket. I brought over an oxygen mask, and told the client "This oxygen will help Sissy to breathe easier while you spend time with her." I slowly moved the mask into place, and the client screamed at the top of her lungs in a tone that could have fightened a demon;

"WHAT IS THAT!!!!!!!!!!!!!!!!!! WHAT ARE YOU GIVING HER?!?!?!??!!!!!!"

Somewhat dumbfounded, I replied "Ma'am, this is OXYGEN to help Sissy breathe while you hold her." (What did she think it was? Poisonous gas we were going to make her and her cat breathe?)

When the clients were ready, and amongst screaming, yelling, and swearing, I administered the euthanasia solution. Sissy stopped struggling to breathe, and passed peacefully. I knew we had done the right thing, despite the drama associated with the decision.

As sad as the loss of a pet is, there's no reason to treat the veterinarian like an enemy!

Friday, January 13, 2012

I woke up this morning after finally getting a night of sleep. Work this week has been outrageous, and actually this entire winter has been busier than usual. To give you some idea of my schedule this week, it went something like this:

Wake up in the afternoon/early evening, shower, get ready for work. Feed my pets. Stumble around the house for awhile, trying to figure out what day it is and get rid of my sleep-deprivation headache. Leave for work, drive somewhere to find food (since there's no groceries or time to go to the store while on 15 hour shifts), arrive at work. Eat my dinner at the staff break table. Clock in, put on lab coat and stethoscope. Run around like a mad-woman for 14-15 hours dealing with situations like the one below. Try to maintain patience, poise, and make sound medical judgements. Finish shift, clock out. Drive home (trying not to fall asleep at the wheel), crash into bed, try to sleep (it's been sunnier than usual this winter, so I've been having a hard time with the sleep part, and additionally, we just moved, so it's even more difficult with everything askew). Repeat. No time for household tasks, cooking, eating, or other such silly things. Needless to say, I'm exhausted.

So after arriving at work one night this week, it was blessedly quiet. Nothing hospitalized, no patients waiting to be seen when I arrived. I got a few things done that have been waiting for weeks, and enjoyed a few hours of peace and quiet. We took a few phone calls, but none of the callers would agree to come in.

The night looked golden - usually after about midnight, the caseload drops off as most people are asleep and not able to know what their pet is or isn't doing. Unfortunately, that wasn't the case this night.

Four clients, three of them disasters, all arrived within 15 minutes of each other.

Client #1 - Young, otherwise healthy dog who had had his first seizure. Fortunately, this patient was stable. Unfortunately, the clients were ridiculous. I spent about 20 minutes talking to them about the most likely diagnosis, epilepsy, and the usual therapy for their pet. As their cute young dog tried to get me to throw his toy so he could fetch it, these clients actually asked me to euthanize their dog. Again, I explained that their pet was stable, that he may never seizure again, and even if he did, it was (usually) manageable with medications. In the middle of my third go-around explaining, I was pulled away for the next client.

Client #2 - 1 year old pomeranian, Sid, presenting for "just not being himself." She stated that this had just happened in the last hour or so. "Just not himself" was a ridiculous understatement - Sid was laterally recumbent and nearly comatose, dripping blood from his penis and definitely critical. The client was acting bizarre, attempted to leave several times, and stated that she had no money to spend to help Sid.

She refused to apply for CareCredit to help herself help Sid. She contacted 3 or 4 relatives, who then each separately called our hospital multiple times.

While I waited for the client to sort out her drama, I tried to help Sid, regardless of the fact that she couldn't pay for services. I passed a urinary catheter, and found that he had multiple bladder stones, including some stuck in his urethra. My technician inquired again about symptoms, and the client changed her story - now stating that she had been holding him all day and that the bloody urine had started that morning. In truth, poor Sid probably had been unable to urinate for several days, and probably had kidney damage as a result.

I went in to speak with her. Any normal human could see that this dog was suffering. It didn't take doctor status to be able to look at the poor thing, unable to move, body temperature falling, dribbling bloody urine and nearly in a coma to make that decision. I gently explained the situation to her. She made multiple more phone calls, gave me way too much information regarding her multiple estranged husbands/baby's daddy/boyfriends, and finally agreed to euthanasia, TWO HOURS after her arrival. She refused treatment for Sid, and without treatment, she knew, even in her drug-altered state, that he would continue to suffer and eventually die. I thought we had resolution of this awful situation.

Client #3 had been waiting in an exam room for much of this time. This client had been calling our office multiple times with a 1 year old chihuahua having difficulty with labor. The dog had one stillborn puppy, and 8 hours had gone by with no further puppies. Green discharge was now coming from her vulva. This is BAD - the remaining fetuses are probably either near dead or already dead, and if the fetuses aren't removed from the uterus, they can decompose and make the bitch very, very sick.

Unfortunately, these clients were complete morons. (You may think I'm being harsh, but just wait and see for yourself). They refused an exam by a doctor (so why did they come in?), they refused to apply for CareCredit (the only payment plan that is available). My technician got vitals on the bitch, who thankfully appeared stable at this time, and recommended they see a low - cost spay/neuter clinic as soon as they opened in the morning, about 7 hours' wait. He explained to them that the wait was not ideal, and she could be very, very sick quickly based on their poor decisions. We gave them contact information for the most affordable low-income spay clinic in our area. The next day, they continued to call, had NOT taken the bitch to be spayed, and her symptoms were worsening. By 5pm, when the spay clinic closes for the day, they never made any sort of arrangements for her care and continued to call us. The spay clinic is subsidized by donors and local government and is able to perform spays well below cost, therefore the cost of a spay at this clinic is actually LESS than our exam fee ALONE. We gave them the tools to save their dog at a VERY low price (we're talking less than $100), and they did nothing. I feel bad for their poor, poor dog, but I feel nothing but contempt for the humans.

Client #4 had also been waiting a very long time to speak with me. I was so happy to walk into the exam room and find a normal person, a friendly dog, and a minor problem which I remedied quickly. The client was friendly, asked good questions, and genuinely loved her pet. I apologized for her long wait and she thanked me for my care of her pet.

Back to client #2
Despite signing the paperwork for euthanasia, which we were performing for free, and was the only right thing to do for her poor dog, the client continued to call family members. Her estranged baby's-daddy-creepy-douchbag-ex-husband came down to the clinic after hour number two of this drama, and refused to let us euthanize the dog.

I argued with him for an hour, but he was completely irrational (and probably on drugs). He said really smart things, including that he had a dog with this problem before who he had fixed by giving it yogurt. Oh, right, yogurt totally clears up KIDNEY FAILURE and bladder stones. Sorry, I forgot when they taught that in EIGHT YEARS of school. My bad.

After the fourth hour of this saga, my patience was completely gone. I informed this man that he needed to put his feelings aside and do the right thing for his pet. He refused. I then told him that he either needed to authorize treatment, to euthanize his dog, or he needed to leave. If he chose to leave, it would be against medical advice and I would contact the animal control authorities and report him for cruelty.

He chose to leave, and signed against medical advice paperwork.

So incredibly infuriating. I contacted the authorities the next morning, and they will be doing a full investigation. I hope they throw the book at him.

All stories contained within this blog are inspired by my life as an emergency veterinarian. Details including but not limited to name, time of visit, species, and age are changed to protect the innocent and crazy alike. Any relationship to persons or animals, living or dead, is purely coincidental.

This isn't web DVM....

These stories are shared to inspire and to entertain. They are not intended to be medical advice. If your pet is sick, the only rational thing to do is have him or her seen (in real life) by a veterinarian.

Who is that masked woman, anyway?

Ever since I was little, I always had the dream of becoming a veterinarian. The dream has been realized, and my passion is emergency medicine. ER work has many pitfalls and disadvantages, but for me, the ability to be there in a moment of crisis and help both a beloved pet and their loving family, is worth the bad days.

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Definitions and commonly seen conditions

Anemia: Low PCV (see below). Anemia can result from external hemorrhage, internal hemorrhage, destruction of blood cells in the body, or inability to make new blood cells in the bone marrow.

Azotemia: Elevation in the BUN (blood urea nitrogen) or creatinine. BUN and creatinine are body wastes typically eliminated by the kidneys; increased levels in the body indicate kidney dysfunction, obstruction of urine, or severe dehydration.

Congestive Heart Failure (CHF): Accumulation of fluid in the lungs due to failure of the heart. Some symptoms include shortness of breath, decreased appetite, rapid breathing rates, coughing, and weakness.

Feline Lower Urinary Tract disease (also called feline idiopathic cystitis): A condition resulting in frequent, painful urination, and in the most severe cases, obstruction of the urethra. FLUTD has several potential causes and is also an extreme emergency.

GDV: Gastric dilatation and volvulus. Occurs in large breed dogs; the stomach fills with gas and twists. An extreme emergency, this condition is treated with stabilization and immediate surgery.

PCV: Packed cell volume. The percentage of red blood cells contained within a given sample of whole blood. Normal for dogs and cats is typically 35%-45%.